Copay Select 80 - 2500 Health Insurance Plan Details

	Copay Select 80 - 2500

Details at a Glance

Plan Type
Network
Office Visit for Primary Doctor
History and Exam: $35 Copay
Office Visit for Specialist
History and Exam: $35 Copay
Coinsurance
20% after deductible
Separate Prescription Drugs Deductible
Tiers 2-4: Combined $200 per person, per calendar year deductible
Prescription Drugs
Tier 1: $15 copay
Tier 2: $35 copay
Tier 3: $65 copay
Tier 4: You pay 25% coinsurance
(Maximum $3,000 per covered person, per calendar year)
(See sample list of drugs)
Health Savings Account (HSA) Eligible
No
Out-of-Network Coverage
Yes (Details in plan brochure below)
Out of Country Coverage
Emergency Care Only

Prescription Drugs Other Coverage
Tier 1: $15 copay
Tier 2: $35 copay
Tier 3: $65 copay
Tier 4: You pay 25% coinsurance
(Maximum $3,000 per covered person, per calendar year)
(See sample list of drugs)
Mail Order for Prescription Drugs
Not Available
Separate Prescription Drugs Deductible
Tiers 2-4: Combined $200 per person, per calendar year deductible

Emergency Room
Illness: 20% Coinsurance after deductible, additional $100 Copay per visit if not admitted; Injury: 20% Coinsurance after deductible
Outpatient Lab/X-Ray
20% Coinsurance after deductible
Outpatient Surgery
20% Coinsurance after deductible
Hospitalization
20% Coinsurance after deductible

Chiropractic Coverage
20% Coinsurance after deductible (limited to $2,000 of covered expenses per calendar year)
Mental Health Coverage
20% Coinsurance after deductible ($50 Max. Benefit Per Visit. $3,000 Max. Benefit for lifetime)